CONSENT FOR EVALUATION AND

2-Hole 1/4 2 3/4 c-to-c
PATIENT CONSENT
AND ACKNOWLEDGEMENT
CONSENT FOR EVALUATION AND TREATMENT
I hereby consent to and authorize U.S. HealthWorks Medical Group, its affiliates, physicians, employees (USHW) to
perform a physical examination and/or medical treatment deemed necessary. Treatment may include, without
limitation, any required examination, medical, diagnostic or laboratory tests and medical procedures ordered by the
physician(s) to be performed by the designated USHW staff. I understand I may refuse treatment at any time. If I am
presenting to USHW for non-regulated substance abuse testing, I voluntarily consent to and authorize USHW to
obtain a specimen of my urine, blood, saliva, breath, hair and/or other specimen, to determine the presence of drugs
and/or alcohol. I understand that certain special medical exams such as physical exams (e.g. fitness for duty, school
or sports) and other services are not intended to diagnose medical conditions, determine treatment needs, or replace
the medical care of my personal physician.
CONSENT TO USE AND DISCLOSE INFORMATION / RECEIPT OF NOTICE OF PRIVACY PRACTICES
I understand that USHW desires that I be fully informed about how my protected health information will be used and
disclosed. I acknowledge that I have reviewed or have been given an opportunity to review the USHW Notice of
Privacy Practices. I may ask for a copy of the notice or can view it electronically at http://www.ushealthworks.com. I
acknowledge that I understand how my information will be used and disclosed, and give my voluntary consent to
USHW to use and disclose my protected health information for reasons as allowed or required as explained in the
Notice.
ASSIGNMENT OF BENEFITS / FINANCIAL RESPONSIBILITY AGREEMENT
• If applicable, where I have insurance coverage to pay for services rendered, I hereby authorize and assign to
USHW any and all payments under the terms of my applicable insurance policies, and hereby obligate each
payer to make payment directly to USHW for services rendered. If applicable, where I am treated on a private pay
basis I understand I am responsible for payment of services in full. I have a right to ask for the charge amounts
before electing treatment.
• If applicable, where I am treated for a workers’ compensation injury or illness USHW will seek payment from the
responsible payer, which is typically the employer or the employer’s workers’ compensation insurance carrier, in
accordance with State or Federal workers’ compensation laws.
• If applicable, for employer directed or required services (e.g. drug testing, physicals, medical surveillance) USHW
will seek payment from the employer. Individual patients may be responsible for payment only as allowed by
State or Federal law.
• Where applicable, I understand that I am responsible to pay for deductibles, copayments and other charges in
accordance with my benefit plan and determinations made by health insurance carriers, or charges determined
by State or Federal workers’ compensation programs, or your employer as allowed by law. Should my account be
referred for collection, I understand that I may have to pay collection expenses incurred by USHW, without
limitation, court costs and attorney’s fees as allowed by law.
By signing this form I acknowledge that I have read and/or had the notice explained to me and I fully understand its
contents. I have been given ample opportunity to ask questions, and any questions have been answered
satisfactorily.
SIGNATURE
Patient Signature:
Patient Name:
ST1001A (3/11)
Date:
Date of Birth:
© US HealthWorks
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PRIVATE PATIENT INFORMATION
PATIENT INFORMATION: (Información del Paciente)Date (Fecha): Name (Nombre): Last (Apellido): First (Nombre):
Current Address (Dirección): City (Ciudad) State (Estado)
Home Phone (No teléfono en casa): (
)
Date of Birth (Fecha Nacimiento): Cell (Celular): (
Work Phone (No teléfono en trabajo):: (
)
Zip (C. Postal)
)
SS: Sex(o):
Emergency Contact (En caso de emergencia) Name (Nombre): Tel: ( )
Marital Status (Estado Marital):  Single (Soltero)  Married (Casado)  Other (Otro):
Employment:  Employed (Empleado)
Student (Estudiante):  FT (Tiempo completo)  PT (Tiempo Parcial)  Other (Otro):
E-mail Address (Correo electrónico): Occupation (Ocupación):
Employer(Empleador) Name (Nombre):
Address (Dirección): City (Ciudad) State (Estado)
Zip (C. Postal)
Have you ever been treated at US HealthWorks before? (Ha sido tratado alguna vez en US HealthWorks?  Yes (Sí)  No
RESPONSIBLE PARTY INFORMATION: (Información de la persona responsable)  Check here if responsible party is also the patient. If so, continue in the next section.
(Si la persona responsable es también el paciente, marque la casilla y continue en la sección siguiente)
Name (Nombre): Last (Apellido): First (Nombre): Sex(o):
Current Address (Dirección): City (Ciudad) State (Estado)
Home Phone (No teléfono en casa): (
)
Zip (C. Postal)
Work Phone (No teléfono en trabajo):: ( )
Date of Birth (Fecha Nacimiento): Cell (Celular): (
)
SS:
PLEASE ANSWER THE FOLLOWING QUESTIONS (Por favor conteste las siguientes preguntas):
Is this visit for a new illness or condition? (¿Se debe esta visita a una nueva enfermedad o condición?)  Yes (Si)  No
Illness Date (Fecha de enfermedad): Similar Illness Date (Fecha con enfermedad similar):
Referring Physician (Médico que Refiere): Patient Insured? (¿Paciente Asegurado?)  Yes (Sí)  No
Bill Employer? (¿Para cobrarle al empleador?) Yes (Sí)  No
Do you have, or are you eligible for Medicare part A or B? (¿Tiene o es elegible para Medicare A o B?)  Yes (Sí)  No
INSURANCE INFORMATION (Información de su compañía de seguros)
Subscriber Name (Suscritor): Last (Apellido): First (Nombre):
Cell (Celular): (
)
Current Address (Dirección): City (Ciudad) State (Estado)
Home Phone (Teléfono en casa): (
)
Zip (C. Postal)
SS: Date of Birth (Fecha Nacimiento):
Relationship to Insured (Relación con asegurado):  Patient (Paciente)  Spouse (Cónyuge)  Child Hijo(a)  Other (Otra):
ST5020 (Rev 11/2012)
© US HealthWorks
2-Hole 1/4 2 3/4 c-to-c
HEALTH HISTORY / HISTORIA MEDICA
URGENT CARE / CUIDADOS DE URGENCIA
TO BETTER ASSESS YOUR HEALTH AND ITS IMPACT IN THE RESOLUTION OF YOUR CONDITION, ANSWER THE FOLLOWING QUESTIONS. CIRCLE ANY SPECIFIC
ITEMS IN EACH SECTION THAT APPLY TO YOU AND EXPLAIN ANY YES ANSWERS IN THE SPACE AT THE BOTTOM OF THE PAGE.
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PAST MEDICAL, FAMILY AND SOCIAL HISTORY
$17(&('(17(60e',&26)$0,/,$5(6<62&,$/(6
No Yes/Si Have you ever had any medical allergies?
No Yes/Si Currently on any medications? If YES, list medications and dosage below.
1
¢Alguna vez ha sufrido de alergias PpGLFDV? 5
¢7RPD alguna medicina? Si responde SI, liste las medicinas y dosis abajo.
2
No Yes/Si Have you ever had recurrent illnesses or major injuries?
No Yes/Si Have you ever had hospitalizations or surgeries?
¢+DVXIUido de enfermedades/ lesiones importantes? 6
¢$OJXQDYH]KDWHQLGRKRVSLWDOL]DFLRQHVXRSHUDFLRQHV"
No Yes/Si Do you currently have a chronic illness such as:
No Yes/Si Have any direct relatives suffered from: blood diseases, cancer, leukemia,
High blood pressure, heart disease, stroke
diabetes, heart disease, high blood pressure, strokes, mental illnesses or other?
Diabetes, thyroid disease, liver disease, kidney disease
Mental illness, seizures or movement disorders?
¢+DQVXIULGRVXVIDPLOLDUHVGLUHFWRVGHDOJXQDHQIHUPHGDGFRPRSUHVLyQ
3
7
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DOWDGLDEHWHVHQIHUPHGDGHVGHOFRUD]yQDWDTXHV convulsiones,
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HQIHUPHGDGHVGHOKtJDGRRULxRQHVRHQIHUPHGDGHVPHQWDOHV"
Diabetes, enfermedades de la tiroides, KtJDGRRULxRQHV
Enfermedades mentales, convulsiones o movimientos involuntarios?
No Yes/Si 'R\RXXVHWREDFFR",Iµ<HV¶VWDWHtype and quantity per day.
No Yes/Si Do you consume alcohol? If YES, state type and quantity.
4
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¢&RQVXPHEHELGDVDOFRKyOLFDV"6LUHVSRQGH6,LQGLTXHWLSR\FDQWLGDG.
REVIEW OF SYSTEMS
/
REVISION DE SISTEMAS
Circle any items that apply in each section and explain further below.
0DUTXHFRQXQFtUFXOR FXDOTXLHUFRQGLFLyQque aplique a su caso HQFDGDVHFFLyQ\H[SOLTXHabajo.
HAVE YOU RECENTLY EXPERIENCED ANY OF THE FOLLOWING?
͎,WZ^EdKh^dRECIENTEMENTE ALGUNOS DE LAS SIGUIENTES CONDICIONES?
No Yes/Si CONSTITUTIONAL
CONSTITUCIONAL
No Yes/Si SKIN
PIEL
9
Fever, chills, fatigue, body aches or weight gain or loss?
16
Cancer, tumors, cysts or other? ¢CiQFHUWXPRUHVTXLVWHVu otros problemas?
Fiebre, escalofrios, fatiga dolor en el cuerpo o cambios significativos de peso?
No Yes/Si HEAD
CABEZA
No Yes/Si EYES
OJOS
10
Trauma, injuries, or frequent or severe headaches?
17
Trauma, injuries, Infections, burning, itching or light sensitivity?
¢Golpes, lesiones o dolores de cabeza?
¢Trauma, lHVLRQHVLQIHFFLRQHVSLFD]yQTXHPD]yQRVHQVLELOLGDGDODOX]?
No Yes/Si CARDIOVASCULAR
CARDIOVASCULAR
No Yes/Si GENITOURINARY
GENITOURINARIO
Palpitations, shortness of breath, chest pain/pressure, swelling in legs/feet?
Blood in urine, painful/frequent urination, kidney stones, venereal diseases?
11
18
¢3DOSLWDFLRQHV GLILFXOWDGSDUDUHVSLUDUSUHVLyQ en el pecho,
¢Orina con sangre o dolor, orina frecuente, FiOFXORVGHULxyQ,
KLQFKD]yQGHODVSLHUQDVRSLHV"
HQIHUPHGDGHVYHQpreas?
No Yes/Si EARS,NOSE,THROAT
OIDOS,NARIZ,GARGANTA
No Yes/Si MUSCULOSKELETAL
086&8/2648(/e7,&2
Ear pain, trouble hearing, sore throat or pain swallowing, sinus pain or disease,
Joint pain, neck or back pain, broken bones?
12
19
nasal allergies?
¢Dolor de otGRVVRUGHUDGRORUde garganta, sinusitis, alergias nasales?
¢'RORUHQODVDUWLFXODFLRQHVGRORUHQODHVSDOGDRHOFXHOORIUDFWXUDV"
No Yes/Si RESPIRATORY
RESPIRATORIO
No Yes/Si NEUROLOGICAL
1(852/Ï*,&2
13
Asthma, wheezing, emphysema, bronchitis, tuberculosis or coughing of blood? 20
Dizziness, muscle weakness, numbness?
¢Asma, silbidos al respirar, enfisema, bronquitis, tuberculosis, tos con sangre?
¢0DUHRVRYpUWLJRGHELOLGDGPXVFXODUIDOWDGHVHQVDFLyQ"
No Yes/Si GASTROINTESTINAL
GASTROINTESTINAL
No Yes/Si ENDOCRINE
ENDOCRINO
Abdominal pain, indigestion or reflux, nausea or vomiting, blood in vomit or
Thirst, increased urination, hair loss, thyroid disease, osteoporosis?
14
stool, constipation, diarrhea, ulcers, diverticulitis?
21
¢'RORUDEGRPLQDOLQGLJHVWLyQRUHIOXMRQDXVHD RYyPLWRVYyPLWRV
¢Sed, aumento de la orina, perdida notable del cabello,
RKHFHVFRQVDQJUHFRQVWLSDFLyQGLDUUHD~OFHUDVGLJHVWLYDV, diverticulitis?
problemas de tiroides, osteoporosis?
No Yes/Si BLOOD DISORDERS, CANCER
ENFERMEDADES DE LA SANGRE
No Yes/Si FOR MEN ONLY
PARA HOMBRES SOLAMENTE
Anemia, spontaneous or easy bleeding, bruising, cancer?
Penile discharge, prostate problems, genital pain or masses?
15
22
¢Anemia, moretones o cardenales, sangramientoFiQFHU"
¢Secresiones en el pene, problemas de SUyVWDWDdolor o masas genitales?
23
No Yes/Si FOR WOMEN ONLY
Painful or irregular menstruation, vaginal discharge or pain?
Are you pregnant?
23
No Yes/Si PARA MUJERES SOLAMENTE
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Esta Usted Embarazada
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I certify that, to the best of my knowledge, the information provided above is complete and correct.
Patient Signature:
Date:
&HUWLILFRTXHODLQIRUPDFLyQVXPLQLVWUDGDDTXtHVFRPSOHWD\FRUUHFWD
Firma del Paciente:
Fecha:
IF ID LABELS ARE USED, AFFIX HERE AND DO NOT COVER ANY OF THE DOCUMENTATION ABOVE.
Name:________________________________________________________ ST5020A (Rev 11/2012)
UC HEALTH HISTORY / HISTORIA MEDICA
Confidential / Confidencial
Incident #:_______________________________ Date:�����������������
© US HealthWorks